Provider Demographics
NPI:1730172826
Name:IRVINE, TIMOTHY E (CRNA)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:E
Last Name:IRVINE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 BAY PARK DR
Mailing Address - Street 2:DEPARTMENT OF SURGERY
Mailing Address - City:OREGON
Mailing Address - State:OH
Mailing Address - Zip Code:43616-4920
Mailing Address - Country:US
Mailing Address - Phone:419-690-7653
Mailing Address - Fax:419-697-7726
Practice Address - Street 1:2801 BAY PARK DR
Practice Address - Street 2:DEPARTMENT OF SURGERY
Practice Address - City:OREGON
Practice Address - State:OH
Practice Address - Zip Code:43616-4920
Practice Address - Country:US
Practice Address - Phone:419-690-7653
Practice Address - Fax:419-697-7726
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN163057367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00459029OtherRRMC
MI4510675Medicaid
MI5182130Medicaid
OH04097AOtherPARAMOUNT
OH0768601Medicaid
OH341881145-003OtherMMO
OH000000287582OtherANTHEM
OH000000479672OtherANTHEM
OH341881145-003OtherMMO
OH0768601Medicaid
OHIR8205918Medicare PIN